RFI Browser

RFI # 1953:
Redundancy Claim vs Claim

Informal
Formal

Submitter

Betty Westbrook

Description

Section 1.12.5 only addresses claim level vs line level redundancy. Can clarification also be provided regarding claim level redundant information, such as that in Rendering 2310D vs Attending 2310A? The TR3 indicates 2310D is “Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim.
AND
When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.)
If not required by this implementation guide, do not send.”

Submitter Assigned Keywords

Attending Rendering

Response

Section 1.12.5 allows for a submitter to send the same information in different parts of a claim for example allowing a rendering provider to be report at both the claim and line level. Redundancy for data is primarily based on the data qualifiers such as the NM101 not the actual data values. Section 1.12.5 does not address reporting the same individual using different type of qualifiers within one section of a claim.

The situational rule for 2310D rendering provider is “Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a “combined claim”, that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send”

To be compliant with the TR3 the rendering and attending provider cannot be the same person since that would not satisfy the first condition of the situational rule

Per RFI 1512 ASC X12 does not govern the receiver's actions when receiving a transaction that is not compliant with the specified implementation guide. Section 2.2.1.1 in TR3s published by the ASC X12 Insurance Subcommittee makes this clear with the statement "The receiver will handle non-compliant transactions based on its business process and any applicable regulations."